Mối liên hệ giữa liệu pháp sắt tiêm tĩnh mạch và nguy cơ tử vong ngắn hạn ở bệnh nhân cao tuổi phẫu thuật gãy xương hông: một nghiên cứu quan sát
Tóm tắt
Thiếu máu là phổ biến ở bệnh nhân gãy xương hông cao tuổi và có liên quan đến việc phục hồi lâu dài và tăng tỷ lệ tử vong sau phẫu thuật. Sắt tiêm tĩnh mạch dường như làm tăng phục hồi hemoglobin và giảm tỷ lệ tử vong ở bệnh nhân phẫu thuật chỉnh hình. Nghiên cứu này đã điều tra mối liên hệ giữa nguy cơ tử vong ngắn hạn và liệu pháp sắt tiêm tĩnh mạch ở những bệnh nhân cao tuổi phẫu thuật gãy xương hông.
Nghiên cứu quan sát này bao gồm 210 bệnh nhân phẫu thuật gãy xương hông từ tháng 7 năm 2018 đến tháng 5 năm 2020. Những bệnh nhân này còn sống và có nồng độ hemoglobin ≤ 6.5 mmol/L vào ngày thứ 3 sau phẫu thuật. Vào tháng 5 năm 2019, một giao thức liệu pháp sắt tiêm tĩnh mạch đã được thực hiện và khuyến nghị sử dụng sắt tiêm tĩnh mạch (Monofer©) nếu nồng độ hemoglobin vào ngày thứ 3 sau phẫu thuật ≤ 6.5 mmol/L. Theo phương pháp điều trị thiếu máu sau phẫu thuật giữa ngày 1 và ngày 3, các bệnh nhân được chia thành bốn nhóm: không điều trị (
Trong số 210 bệnh nhân, 17 (8.1%) đã chết trong vòng 30 ngày sau phẫu thuật. Tỷ lệ tử vong ở những bệnh nhân nhận IV Monofer thấp hơn đáng kể so với nhóm không điều trị (HR 0.17, 95% CI [0.03–0.93],
IV Monofer vào ngày thứ 3 sau phẫu thuật ở bệnh nhân gãy xương hông cao tuổi có vẻ như làm giảm tỷ lệ tử vong sau 30 ngày so với nhóm không điều trị. Không phát hiện sự khác biệt đáng kể về mức hemoglobin giữa 14 và 30 ngày sau phẫu thuật giữa các nhóm điều trị, mặc dù điều này được đánh giá trong một nhóm bệnh nhân có mức hemoglobin có sẵn, cần nghiên cứu thêm.
Từ khóa
Tài liệu tham khảo
Foss NB, Kristensen MT, Kehlet H. Anaemia impedes functional mobility after hip fracture surgery. Age Ageing. 2008;37(2):173–8. https://doi.org/10.1093/ageing/afm161.
Gruson KI, Aharonoff GB, Egol KA, Zuckerman JD, Koval KJ. The relationship between admission hemoglobin level and outcome after hip fracture. J Orthop Trauma. 2002;16(1):39–44. https://doi.org/10.1097/00005131-200201000-00009.
Halm EA, Wang JJ, Boockvar K, Penrod J, Silberzweig SB, Magaziner J, et al. The effect of perioperative anemia on clinical and functional outcomes in patients with hip fracture. J Orthop Trauma. 2004;18(6):369–74. https://doi.org/10.1097/00005131-200407000-00007.
Vochteloo AJH, Borger Van Der Burg BL, Mertens BJA, Niggebrugge AHP, De Vries MR, Tuinebreijer WE, et al. Outcome in hip fracture patients related to anemia at admission and allogeneic blood transfusion: an analysis of 1262 surgically treated patients. BMC Musculoskelet Disord. 2011;12(1):262 Available from: http://www.biomedcentral.com/1471-2474/12/262.
Dunne JR, Malone D, Tracy JK, Gannon C, Napolitano LM. Perioperative anemia: An independent risk factor for infection, mortality, and resource utilization in surgery. J Surg Res. 2002;102(2):237–44. https://doi.org/10.1006/jsre.2001.6330.
Wu WC, Schifftner TL, Henderson WG, Eaton CB, Poses RM, Uttley G, et al. Preoperative hematocrit levels and postoperative outcomes in older patients undergoing noncardiac surgery. J Am Med Assoc. 2007;297(22):2481–8. https://doi.org/10.1001/jama.297.22.2481.
Van Iperen CE, Kraaijenhagen RJ, Biesma DH, Beguin Y, Marx JJM, Van De Wiel A. Iron metabolism and erythropoiesis after surgery. Br J Surg. 1998;85(1):41–5. https://doi.org/10.1046/j.1365-2168.1998.00571.x.
Muñoz M, Romero A, Morales M, Campos A, García-Erce JA, Ramírez G. Iron metabolism, inflammation and anemia in critically ill patients. A cross-sectional study. Nutr Hosp. 2005;20(2):115–20.
Van De Wiel A. Anemia in critically ill patients. Eur J Intern Med. 2004;15(8):481–6. https://doi.org/10.1016/j.ejim.2004.09.004.
Hill GE, Frawley WH, Griffith KE, Forestner JE, Minei JP. Allogeneicblood transfusion increases the risk of postoperative bacterial infection: A meta-analysis. J Trauma. 2003;52(5):908–14.
Shokoohi A, Stanworth S, Mistry D, Lamb S, Staves J, Murphy MF. The risks of red cell transfusion for hip fracture surgery in the elderly. Vox Sang. 2012;103(3):223–30. https://doi.org/10.1111/j.1423-0410.2012.01606.x.
Cuenca J, García-Erce JA, Martínez F, Pérez-Serrano L, Herrera A, Muñoz M. Perioperative intravenous iron, with or without erythropoietin, plus restrictive transfusion protocol reduce the need for allogeneic blood after knee replacement surgery. Transfusion. 2006;46(7):1112–9. https://doi.org/10.1111/j.1537-2995.2006.00859.x.
National Blood Authority Australia. Three pillars of patient blood management [Internet]. Commonwealth of Australia; 2012. p. 1. Available from: https://www.blood.gov.au/system/files/documents/pbm-3-pillars.pdf. [cited 2020 Aug 24]
Leahy MF, Hofmann A, Towler S, Trentino KM, Burrows SA, Swain SG, et al. Improved outcomes and reduced costs associated with a health-system–wide patient blood management program: a retrospective observational study in four major adult tertiary-care hospitals. Transfusion. 2017;57(6):1347–58. https://doi.org/10.1111/trf.14006.
Meybohm P, Herrmann E, Steinbicker AU, Wittmann M, Gruenewald M, Fischer D, et al. Patient blood management is associated with a substantial reduction of red blood cell utilization and safe for patient’s outcome: a prospective, multicenter cohort study with a noninferiority design. Ann Surg. 2016;264(2):203–11. https://doi.org/10.1097/SLA.0000000000001747.
Muñoz M, Acheson AG, Bisbe E, Butcher A, Gómez-Ramírez S, Khalafallah AA, et al. An international consensus statement on the management of postoperative anaemia after major surgical procedures. Anaesthesia. 2018;73(11):1418–31. https://doi.org/10.1111/anae.14358.
Rineau E, Chaudet A, Chassier C, Bizot P, Lasocki S. Implementing a blood management protocol during the entire perioperative period allows a reduction in transfusion rate in major orthopedic surgery: a before-after study. Transfusion. 2016;56(3):673–81. https://doi.org/10.1111/trf.13468.
Holt JB, Miller BJ, Callaghan JJ, Clark CR, Willenborg MD, Noiseux NO. Minimizing blood transfusion in total hip and knee arthroplasty through a multimodal approach. J Arthroplast. 2016;31(2):378–82 Available from: https://doi.org/10.1016/j.arth.2015.08.025.
Yoon BH, Lee BS, Won H, Kim HK, Lee YK, Koo KH. Preoperative iron supplementation and restrictive transfusion strategy in hip fracture surgery. CiOS Clin Orthop Surg. 2019;11(3):265–9. https://doi.org/10.4055/cios.2019.11.3.265.
Cuenca J, García-Erce JA, Martínez AA, Solano VM, Molina J, Muñoz M. Role of parenteral iron in the management of anaemia in the elderly patient undergoing displaced subcapital hip fracture repair: preliminary data. Arch Orthop Trauma Surg. 2005;125(5):342–7. https://doi.org/10.1007/s00402-005-0809-3.
García-Erce JA, Cuenca J, Muñoz M, Izuel M, Martínez AA, Herrera A, et al. Perioperative stimulation of erythropoiesis with intravenous iron and erythropoietin reduces transfusion requirements in patients with hip fracture. A prospective observational study. Vox Sang. 2005;88:235–43.
Frew N, Alexander D, Hood J, Acornley A. Impact of a blood management protocol on transfusion rates and outcomes following total hip and knee arthroplasty. Ann R Coll Surg Engl. 2016;98(6):380–6. https://doi.org/10.1308/rcsann.2016.0139.
Muñoz M, Gõmez-Ramírez S, Cuenca J, García-Erce JA, Iglesias-Aparicio D, Haman-Alcober S, et al. Very-short-term perioperative intravenous iron administration and postoperative outcome in major orthopedic surgery: a pooled analysis of observational data from 2547 patients. Transfusion. 2014;54(2):289–99.
Johansson PI, Rasmussen AS, Thomsen LL. Intravenous iron isomaltoside 1000 (Monofer®) reduces postoperative anaemia in preoperatively non-anaemic patients undergoing elective or subacute coronary artery bypass graft, valve replacement or a combination thereof: a randomized double-blind placebo. Vox Sang. 2015;109(3):257–66.
Muñoz M, Naveira E, Seara J, Cordero J. Effects of postoperative intravenous iron on transfusion requirements after lower limb arthroplasty. Br J Anaesth. 2012;108(3):532–4. https://doi.org/10.1093/bja/aes012.
Pujol-Nicolas A, Morrison R, Casson C, Khan S, Marriott A, Tiplady C, et al. Preoperative screening and intervention for mild anemia with low iron stores in elective hip and knee arthroplasty. Transfusion. 2017;57(12):3049–57. https://doi.org/10.1111/trf.14372.
Smith A, Moon T, Pak T, Park B, Urman RD. Preoperative anemia treatment with intravenous iron in patients undergoing major orthopedic surgery: a systematic review. Geriatr Orthop Surg Rehabil. 2020;11:215145932093509. https://doi.org/10.1177/2151459320935094.
Kim SK, Seo WY, Kim HJ, Yoo JJ. Postoperative intravenous ferric carboxymaltose reduces transfusion amounts after orthopedic hip surgery. CiOS Clin Orthop Surg. 2018;10(1):20–5. https://doi.org/10.4055/cios.2018.10.1.20.
Moppett IK, Rowlands M, Mannings AM, Marufu TC, Sahota O, Yeung J. The effect of intravenous iron on erythropoiesis in older people with hip fracture. Age Ageing. 2019;48(5):751–5. https://doi.org/10.1093/ageing/afz049.
Rowlands M, Forward DP, Sahota O, Moppett IK. The effect of intravenous iron on postoperative transfusion requirements in hip fracture patients: study protocol for a randomized controlled trial. Trials. 2013;14(1):1 Available from: Trials.
Mynster T, Krøijer R. Klinisk Retningslinje │Kraeft DCCG [Internet]. [cited 2020 Aug 24]. Available from: www.dmcg.dk/kliniske-retningslinjer
Pollock RF, Muduma G. Intravenous iron treatments for iron deficiency anemia in inflammatory bowel disease: a budget impact analysis of iron isomaltoside 1000 (Monofer) in the UK. Expert Opin Drug Deliv. 2017;14(12):1439–46 Available from: https://doi.org/10.1080/17425247.2017.1393412.
Mørch MM, Hansen LT. Monofer, intravenøs behandling af jernmangel - Ældremedicinsk afsnit 205B og Ortopædkirurgisk afsnit 109 [Internet]. [cited 2021 Mar 4]. Available from: https://pri.rn.dk/Sider/30366.aspx
Pharmacosmos. Monofer 100 mg/ml solution for injection/infusion - Summary of Product Characteristics (SmPC) - (emc) [Internet]. [cited 2021 Mar 4]. Available from: https://www.medicines.org.uk/emc/medicine/23669
Bæch J. Blodtransfusion, gældende for Region Nordjylland [Internet]. [cited 2021 Mar 4]. Available from: https://pri.rn.dk/Sider/6658.aspx
Masnoon N, Shakib S, Kalisch-Ellett L, Caughey GE. What is polypharmacy? A systematic review of definitions. BMC Geriatr. 2017 Oct;17(1):230. https://doi.org/10.1186/s12877-017-0621-2.
Charlson ME, Pompei P, Ales KL, MacKenzie CR. A new method of classifying prognostic comorbidity in longitudinal studies: development and validation. J Chronic Dis. 1987;40(5):373–83. https://doi.org/10.1016/0021-9681(87)90171-8.
Charlson M, Szatrowski TP, Peterson J, Gold J. Validation of a combined comorbidity index. J Clin Epidemiol. 1994 Nov;47(11):1245–51. https://doi.org/10.1016/0895-4356(94)90129-5.
R Core Team. R: A language and environment for statistical computing. Vienna: R Foundation for Statistical Computing; 2018.
Serrano-Trenas JA, Ugalde PF, Cabello LM, Chofles LC, Lázaro PS, Benítez PC. Role of perioperative intravenous iron therapy in elderly hip fracture patients: a single-center randomized controlled trial. Transfusion. 2011;51(1):97–104. https://doi.org/10.1111/j.1537-2995.2010.02769.x.
Parker MJ. Iron supplementation for anemia after hip fracture surgery: a randomized trial of 300 patients. J Bone Jt Surg - Ser A. 2010;92(2):265–9. https://doi.org/10.2106/JBJS.I.00883.
Heschl M, Gombotz H, Haslinger-Eisterer B, Hofmann A, Böhler N, Meier J. The efficacy of pre-operative preparation with intravenous iron and/or erythropoietin in anaemic patients undergoing orthopaedic surgery. Eur J Anaesthesiol. 2018;35(4):289–97. https://doi.org/10.1097/EJA.0000000000000752.
Bernabeu-Wittel M, Romero M, Ollero-Baturone M, Aparicio R, Murcia-Zaragoza J, Rincón-Gómez M, et al. Ferric carboxymaltose with or without erythropoietin in anemic patients with hip fracture: a randomized clinical trial. Transfusion. 2016;56(9):2199–211. https://doi.org/10.1111/trf.13624.
Derman R, Roman E, Modiano MR, Achebe MM, Thomsen LL, Auerbach M. A randomized trial of iron isomaltoside versus iron sucrose in patients with iron deficiency anemia. Am J Hematol. 2017;92(3):286–91. https://doi.org/10.1002/ajh.24633.